Expert Opinions: Dr. Theodoros Teknos, Department of Otolaryngology, Case Western Reserve University

 

Expert Opinions: Dr. Theodoros Teknos 
President & Scientific Director, University Hospitals Seidman Cancer Center,
Deputy Director of the Case Comprehensive Cancer Center
Professor, Department of Otolaryngology,
School of Medicine, Case Western Reserve University
Cleveland, OH, USA

Dr. Theodoros Teknos is a world-renowned academic Otolaryngologist/Head and Neck Surgeon. He earned his MD from Harvard Medical School and trained in Otolaryngology at Massachusetts Eye and Ear Infirmary and subspecialized in head and neck oncology, skull base and microvascular reconstruction at Vanderbilt University Medical Center. During his career, he has held multiple leadership positions at several top-notch institutions including the University of Michigan, the Ohio State University and Case Western Reserve University. His research interests include HNSCC carcinogenesis cancer stem cell biology and biologic predictors of tumor resistance to therapy. He is one of the most cited researchers in the field with >200 published papers, ~10.000 citations and an h-index=56. 

1. Dr. Teknos, why did you choose to specialize in Otolaryngology? What attracted you to the field then, and what attracts you now?

When I started medical school I had a sense that I wanted to become a surgeon, although I wasn’t wedded to the idea. Like many students, as I rotated through the different specialties, all of them appealed to me! I enjoyed every rotation, but was strongly drawn to surgical fields as a whole.  Two things that appealed to me about Otolaryngology were: 1) the enormous breadth of the field encompassing both pediatric and adult patients and 2) the complex anatomy of the head and neck region.  But what really “sealed the deal” for me were the wonderful mentors I encountered in the field.  When I look back it was a combination of the importance of the head and neck area, the complexity of the anatomy and the mentors that I had, who inspired me to pursue a career in the field.

    2. You are subspecialized in Head and Neck Surgical Oncology. HNSCC is a challenging disease and patient outcomes can occasionally be dismal (i.e., survival and QoL). How challenging is this for you and how do you handle it?

The opportunity to improve both survival and quality of life outcomes were motivating factors for me to pursue head and neck surgery. During my training in Otolaryngology, free flap surgery was just beginning to take off, and I witnessed firsthand how reconstructive surgery could dramatically improve the quality of patients’ lives. Furthermore, there were many studies illustrating that due to the success of reconstruction,  wider surgical resections were possible resulting in improved survival outcomes in flap patients. Also, from a scientific standpoint what better population to focus on than one where survival hasn’t improved for many decades? That realization intellectually challenged me to better understand the biology of head and neck cancer and to work diligently to develop novel therapeutic approaches for this patient population.  

Finally, I believe that more so than any other disease site, head and neck cancer patients deserve physicians who are compassionate, kind and caring.  Patient’s appreciate a physician who provides them with exceptional care but also let’s them know when medical science has reached the limit of its capabilities.  Too often, physicians are uncomfortable with these conversations but what separates “good” from “great” doctors is the ability to compassionately deliver this difficult message and provide an orderly transition to end of life care.

    3. Now here’s  a tricky question. You mentioned that you don’t consider dismal survival as a negative. Is there something in the field or in the subspecialty of interest that you feel is a negative? Is there anything that you don’t like that much?

In head and neck surgery? Not really. To be honest, you talk to a lot of physicians and they’ll say “I regret going into my specialty and if I could do it all over again I would do something else”.  I can honestly say that I’ve been thrilled with my career choice. I do not have a single regret about my choice of becoming a head and neck surgeon. In fact it’s been very gratifying because, with the understanding of HPV-related malignancies, the improved survival outcomes and the burgeoning research discoveries,  I’ve witnessed a revolution in our field. Not many people can be witnesses to such an amazing time in medical history.  I feel very fortunate to have made the career choice I did.

Thank you! That’s great, very encouraging to hear.

    4. You’ve mentioned research a couple of times in our discussion so far, so I’d like to focus my next question over there. There is a discussion in the field about the importance of attracting/producing more surgeon-scientists. As of today, you have ~10.000 citations and a stellar h-index=56 (Scopus, 1/14/21). How do you find the balance between the two, and also being the Director of CWRU’s Cancer Center?

That’s a great question. When I started in Otolaryngology-Head and Neck Surgery and then specifically in head and neck cancer, there weren’t a lot of surgeon-scientists and the field was small. The economics of healthcare were different. You could be a “triple-threat” physician (a clinician, an educator, and a scientist) and do all of those things well. But with the rapidity of scientific discovery, all of those positions are full-time jobs now. So I don’t think it's possible in this day and age for one person to be an expert in science, an expert in clinical care, and expert in administration/education.  My focus is primarily to remain an expert in the surgical care of patients. Today’s surgeon-scientists must work in teams and they must embrace team science.

 

“No matter how brilliant someone may be, they’re not as effective as they would be by being part of a team.”

 

So it can’t be a one man show anymore.

One man shows have been cancelled. No matter how brilliant someone may be, they’re not as effective as they would be by being part of a team. Personally, through collaborations with people much smarter than I am, have I been able to learn and contribute to the scientific underpinnings of head and neck cancer.

 

    5. Could you briefly describe a typical working week of yours?

I think it has changed throughout the course of my career. It’s very different today than it was 20 years ago. Today most of my week is administrative, because I’m the president of a Cancer Hospital and a Deputy Director of a Comprehensive Cancer Program. I spend 4-5 days weekly in strategic discussions about cancer care delivery, and cancer programs.  Clinically, I remain active 1-2 days per week caring for head and neck cancer patients in the clinic and OR.  

Earlier in my career, patient care dominated my time. Through the years my effort has changed from a combination of clinical and research effort, to equally apportioned clinical-research-admin time during my mid career years, to primarily administrative effort currently. Today my workweek is still as long as it was when I was a junior faculty member! It’s still 60 plus hours a week, but it's primarily administrative, strategic, faculty mentoring for ~80% of my time, and then 20% of the time is clinical.

 

    6. You mentioned mentoring, and also I recently read an article of yours, published in Oto-HNS about mentoring, so I wanted to ask you in what ways did mentoring affect your academic career?

For me mentoring is the reason I chose to go into academic medicine. I think being a mentor to medical students, residents and fellows has always been the most satisfying part of my career. Helping others achieve their goals, dreams, and aspirations gives me the most joy. So, it’s always been my mission as an attending to teach, to mentor and hopefully to inspire others to pursue Otolaryngology. And it still is today. Today, it's more peer-mentoring: I lead a cancer program and I try to mentor junior attendings, residents and fellows to become more academically-minded and help them succeed.

My mother was a teacher and she instilled that belief in me: if you’re being a mentor and a teacher, you’re successful when your students and mentees exceed what you’ve achieved. That’s always the way I’ve approached mentoring and it gives me great personal satisfaction to see my fellows, my residents, and my students excel. I’ve been around long enough to see my fellows becoming department chairs, cancer center directors, and corporate CEO’s and knowing that I helped them in some minor way to achieve their dreams is a thrill beyond words.

    7. What in your opinion makes a strong aspiring Otolaryngologist, a strong applicant? What are you looking for? Could you give examples of things that stand out in an application/interview?

When I look at candidates, especially for Otolaryngology, it’s astounding to see the qualifications of people who are applying into Otolaryngology.  It's very hard to differentiate between candidates because they’re all so exceptional! You know, anybody you talk to who is my age will tell you “I would never get in if I was applying now”.

But I look for three things. These are the characteristics of what I look for in any sort of employee now, but I think it’s most important for very competitive specialties like Otolaryngology. I want them to be humble, hungry and smart. Sometimes this doesn’t come across in a CV per se, but I think that’s why the interviews are so important. These characteristics are reflective of emotional intelligence.

There are many who are book smart, who are hungry and ambitious, but fail miserably in complex emotionally charged situations. Knowing how to behave in complex situations, controlling your emotions and no matter what circumstance, having a positive approach towards problem solving is rare, even with amongst really bright students such as those pursuing Otolaryngology.

    8. And as you mentioned, you’re waiting to see these things in the interview- I suppose most of the time it can’t be seen through the papers, at least most of the time, right?

Yeah, and that’s why as an advisor, I tell applicants that the most important component of the process is the interview. There’s no question, that a rigorous initial screening process is undertaken by each residency program in which an applicant’s entire body of work is evaluated.  This is primarily, however, to determine which applicants will be invited for an interviews.  Any applicant who is invited for an interview has met the academic standard to be a resident in that program.  The rank list however is entirely based on the interview performance.  It trumps everything else in an applicant’s CV. I have witness countless episodes of outstanding candidates who perform poorly on an interview and ultimately end up ranked very low (or not at all) on a program’s rank list.  The opposite occurs as well; an applicant doesn’t appear as accomplished but meshes well with the departmental culture and ends up at the top of the list.

    9. As you mentioned, we did have the HPV revolution, we did have the revolution of reconstructive surgery, we have trans-oral robotic surgery right now, what else do you see coming next? Where do you see the field in the next years?

I think all of cancer care and specifically head and neck cancer care is going to be most impacted by genomic medicine and immunotherapy. Just like most fields we’re learning more and more about individual malignancies and are tailoring treatment to patient’s specific genetic mutations. I think the era of rapid sequencing and determining which treatments are best for your tumor based on molecular determinants, has begun to transform the field and this transformation will accelerate in the next few years. Unquestionably however, the burgeoning field of immunotherapy will dramatically change how we treat head and neck cancer patients in the years to come.  Currently, 20% of head and neck tumors respond to immunotherapy regimens. Determining the pathways of resistence and designing approaches to overcome this phenomenon will be a major focus of research and clinical trial efforts in the years to come. Furthermore, advances in CAR-T therapy and cancer vaccination strategies will complement our immune system’s ability to detect and eradicate tumors with “living drugs”.

 

Thank you Dr. Teknos for sharing your knowledge and experience with me and our readers!